A recent report describes a case of a 78-year-old female who presented with yellow discoloration and lifting of the right 4th fingernail for the previous 3 months. She described a history of scleroderma, hypertension, osteoarthritis, osteoporosis, iron-deficiency anemia and gastroesophageal reflux. 

Clinical examination of the fingernails revealed sclerodactyly, digital ulceration and severe onycholysis of the right 4th fingernail. Toenails showed mild yellowness and thickening.

Histopathology of fingernail clippings revealed extensive infiltration of large septated hyphal forms, which were highlighted by PAS and GMS stains, and rare spores. Toenail clippings came negative for fungal and yeast elements. 

X-ray of the right hand revealed diffuse osseous demineralization, degenerative changes at the wrist and triscaphe joints, and flexion deformity at the 2nd to 5th proximal interphalangeal joints, in accordance with the history of osteoporosis, osteoarthritis and scleroderma, respectively.

The onychomycosis severity index was 12, indicating moderate onychomycosis. Due to her autoimmune history and concomitant medications, instead of systemic medications, she received topical treatment with efinaconazole 10% solution nightly. After 3 months of treatment, she displayed increased clear proximal nail growth, along with green nail plate discoloration, consistent with concomitant Pseudomonas aeruginosa colonization. She was advised to continue efinaconazole 10% solution along with the newly added gentamicin 0.3% solution for P. aeruginosa treatment. After 6 months of treatment with topical efinaconazole 10% solution, her affected nail exhibited a clinical cure.

Source: Miller RC, Lipner SR. Treatment of fingernail onychomycosis with efinaconazole 10% solution in a patient with scleroderma: a case report. Skin Appendage Disord. 2022;8(4):350-4.